Pega and RPA: Top 5 quick ROI opportunities in healthcare automation

Published: April 24, 2018

Pega's acquisition of OpenSpan has triggered a lot of excitement among customers, competition, and service providers. The acquisition has opened up a whole lot of avenues for overcoming the business challenges healthcare payers are facing today on account of mundane manual tasks and also due to use of multiple silo systems.

These organizations, in their quest to increase efficiency and improve quality, are excited to leverage Robotic Process automation (RPA) but lack an understanding on the complexity of integrating business process management (BPM) with RPA, which includes how to position RPA with the existing BPM.

However, this challenge can be overcome by Pega BPM with RPA for healthcare capabilities, which encompass robotics, analytics, and case management. As you read through this blog, it would be worth imagining how Pega's process/rules capabilities would effectively leverage RPA components as and when required to streamline organizational business processes.

With this in mind, and visualizing the power of robotics process automation on top of Pega BPM, the following could possibly be the quick ROI opportunities in the healthcare automation space:

Pre and Post Adjudication Edits

Healthcare payers are losing on an average of $3.2 billion every year from inefficient and highly manual processes. Payers spend humongous effort on making the claim edits, which includes routine actions like:

  • Checking and fixing the claim for member eligibility, timely filing and duplicate claims
  • Searching and extracting other required data from different systems like provider data, referral, claims history, etc.

Taking advantage of the OpenSpan capabilities, by systematically recording and triggering the actions as and when required, Pega can automate the above mundane actions to a greater level.

Provider Credentialing

Provider credentialing is a critical business activity within every payer organizations. Since it involves dealing with sensitive information and hectic processes, this activity includes verification of information provided by the provider for contracting with the payer.

It involves checking a lot of external source websites to verify the license, exclusions, insurance, education, etc. This could be easily achieved with OpenSpan's crawling and scraping capabilities, and in the process automate 90% of the day-to-day provider credentialing.

Report Preparation for Authorities

A payer needs to submit reports to the state, federal, and other independent agencies like CMS, Medicaid ,NCQA on a periodic basis and the count of reports increase if the payer is an MCO (Managed Care organization). The entire process is mundane and a time consuming effort; but payers are required to follow this process. Usually the information is extracted from different core processing systems, and thereafter processed, formatted and presented as required by the agencies.

This area has a high degree of automation potential and Pega's acquisition of OpenSpan capabilities can go a long way in making it happen.

Customer Care Agents

This use case is a generic one, but there is a perfect fit for this in the healthcare business. Today's healthcare market is seeing a lot of acquisitions resulting in the consolidation of customer service. This means a single contact for all the beneficiaries, but different systems for the agent who engages those beneficiaries.

Such a business problem is usually solved by integration of systems like web services or other mode, but RPA on Pega BPM would bring a different dimension to this challenge with the robotic automation presenting information to the agent on a common screen.

Provider Data Management Between Siloed Systems

One of the biggest challenges faced by the healthcare organizations today is building "One single source of truth" on the provider data for the whole of the organization. Ideally there has to be one! But as organizations grow big and with the perpetual growth of provider data through core processing system from different siloed departments and systems, data management has become a nightmare for organizations.

A systematic step-by-step action of users with a strong BPM is a solution to this problem. Couple this with RPA, and the organization can reap immense benefits including streamlining data management, better decision making, and enabling quicker ROI.


It can be seen that there is a high possibility of automation for about 85-95% of human action in the above scenarios and the remaining fallouts can be processed by human interventions through exception handling methods of Pega BPM.

Automation in the healthcare industry is not new, but an effective combination of Pega's power with RPA's automation capabilities will be a game changer for the industry and no doubt will bring quicker ROI when rightly implemented.

Modernize your care, improve patient outcomes

Unlock the potential of AI/ML-powered solutions

Related content